Incremental Costs of Voucher Scheme - Chrispus Mayora

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Chrispus Mayora of the Makerere University School of Public Health looks at the incremental costs of implementing a voucher scheme for ante-natal, delivery and post-natal care in several districts in Uganda.

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Incremental Costs of Voucher Scheme - Chrispus Mayora

  1. 1. Understanding the Incremental cost of Increasing Access to Maternal Health Care Services: Perspectives from a Voucher Scheme in Eastern Uganda <ul><li>C. Mayora, E. Ekirapa-Kiracho, F. Ssengooba , S.O. Baine, O. Okui </li></ul><ul><li>Acknowledgements </li></ul><ul><li>DFID </li></ul><ul><li>Gates Foundation </li></ul><ul><li>MU-JHU </li></ul><ul><li>District officials </li></ul><ul><li>Health workers </li></ul><ul><li>FHS Partners ( JHU, IDS, ICDDRB, CHEI, UIN,IHMR) </li></ul>[Uganda]
  2. 2. Introduction <ul><li>With MMR continuing to pause a global challenge and more especially in SSA, policy makers and development partners are preoccupied with how to tackle the challenge </li></ul><ul><li>Studies identify failure to access supervised deliveries, and receive emergency obstetric care as major causes </li></ul><ul><li>These are attributed to distance, geographical inaccessibility as well as socioeconomic factors </li></ul>
  3. 3. Introduction <ul><li>In Uganda e.g. only 41% deliver at health facilities, 42% supervised deliveries, even then only 20% of facility deliveries are from rural areas, and 27% from lower SEQ </li></ul><ul><li>Yet, up to 75% of deaths can be averted by ensuring timely access to obstetric care and related maternal care-WHO </li></ul><ul><li>To address these issues, a voucher scheme was launched by FHS, to try and address these challenges as well as investigate impact of DSF and SSF to service uptake </li></ul>[Uganda]
  4. 4. Introduction <ul><li>Indeed evidence shows that vouchers schemes are increasingly being used to subsidise vulnerable populations to access critical services, e.g. in Nicaragua(STIs), Bangladesh(RH), Cambodia, and Kenya, and Uganda </li></ul><ul><li>However, limited studies have been conducted to ascertain the cost-effectiveness of these voucher/subsidy schemes, especially in developing countries </li></ul>[Uganda]
  5. 5. AIM <ul><li>In this paper, we estimate incremental costs of efforts through subsidization(vouchers) of increasing access to maternal healthcare, drawing from a voucher scheme implemented in Eastern Uganda </li></ul><ul><li>We however underscore the limitations attributed to CEA, that relate to under-estimation of the wider economic effects of interventions, including total economic benefits resulting from for example life-saved </li></ul>
  6. 6. Voucher Scheme package <ul><li>voucher entitled pregnant women to transport to and from health facility </li></ul><ul><li>Entitled pregnant mother to package of maternal services, ANCs ( Pilot), Delivery and PNC. </li></ul>[Uganda]
  7. 7. Voucher scheme package <ul><li>Health system strengthening component that included training of health workers, provision of basic equipment, drugs and supplies and support supervision. </li></ul><ul><li>Costs of transport for a return trip on average ranged from USD1.8-USD4.5 </li></ul>[Uganda]
  8. 8. Cost price of Health Services(USD) [Uganda] Service Pilot Phase (De’9-may’10) Implementation(ju’10-fe’11) Implementation (mar’11-de’11) Gv’t PNFP Gv’t PNFP Gv’t PNFP ANC1 0.9 1.14 0.4 0.55 0.4 0.55 A2,3,4 1.0 1.36 0.4 0.55 0.4 0.55 DEL 5.1 6.82 2.7 3.64 4.1 5.45 C/S 51.1 68.18 29.5 59.09 27.3 54.55 PNC 1.0 1.36 0.4 0.55 0.5 0.55
  9. 9. Methodology <ul><li>We use the ingredients approach for costing </li></ul><ul><li>Costs included are from the provider’s perspective </li></ul><ul><li>Costs are captured for the implementation year (June2010-June 2011) </li></ul>[Uganda]
  10. 10. Cost Categories [Uganda] COST CATEGORY DESCRIPTION Voucher costs Transport and service voucher reimbursements, voucher printing, distribution, and transporters’ identification prints(cards) H. S. Strengthening Health workers’ trainings, procurements of basic equipment, drugs and supplies and regular support supervisions. Sensitization &mobilization Stakeholder workshops at community, facility and district levels, talk shows and radio messaging, printing of posters production of documentary, hire of film vans, etc. Administrative costs Costs relating to personnel, field coordination, field supervision, planning activities, regular scheme reviews by faculty, etc..
  11. 11. Methodology <ul><li>We collect costs from project accountabilities and financial records </li></ul><ul><li>Estimate the average transport cost for deliveries by looking at number of women transported and total transport vouchers costs </li></ul><ul><li>Estimate the incremental costs by calculating additional costs and additional effects </li></ul>[Uganda]
  12. 12. Results: Summary costs on voucher reimbursement [Uganda] Activity Amount (Ug. Shs) Amount (USD) Total cost Service Vouchers 87,680 95,866 Admin costs for payment 4135 Contingencies 241 Printing vouchers 3809.8 Transport vouchers 174,666.08 185,376 Admin costs 4793 Contingency 482.85 Printing vouchers 3809.8 Printing Identification cards 1622
  13. 13. Results: Summary costs on Health System Strengthening [Uganda] Activity Amount(USD) Equipment , drugs, sundries 101,822 Support Supervision 13,917 Training of Health Workers 8,973 Training materials 616 Total 125,328
  14. 14. Results: Summary Distribution of costs by major activity(Percentage Distribution) [Uganda] Activity Amount(USD) Percentage Service voucher costs 95,866 19.1 Transport Voucher costs 185,376 36.9 Health Systems Strengthening 125,328 24.9 Sensitization and mobilization 46,396 9.2 Administration 49,869 9.9 Total 502,835 100.00
  15. 15. Graph showing share of key-scheme activity costs as % of total costs [Uganda]
  16. 16. Service vouchers reimbursed in intervention period [Uganda] Service Total Percentage of total ANCs 6302 15.9 Delivery 22558 57.0 PNC 9678 24.4 C-Section 213 0.5 False Labour 810 2.0
  17. 17. Results [Uganda] Total cost transport vouchers ( excluding referral transport) No of women transported Cost per woman transported $183,439 39,348 $4.6
  18. 18. Results [Uganda] Incremental cost for deliveries Additional deliveries Incremental cost per additional institutional delivery $304,248 19,288 $15.7 Incremental cost for PNC’s Additional PNC visits Incremental cost per additional PNC $102,352 7452 $13.73
  19. 19. Conclusion <ul><li>Incremental costs per additional delivery and PNC appear small </li></ul><ul><li>However cost of scaling up such a scheme in a large population with high fertility ( 6.7) likely to be huge offering a challenge to sustainability in a developing country facing competing priorities </li></ul><ul><li>To ensure the success of voucher scheme, health system strengthening must be put in place, to guarantee quality outcomes </li></ul>[Uganda]
  20. 20. Policy Implication <ul><li>Finding ways of mobilizing existing community resources and taking advantage of technology ( eg e payment)may enhance sustainability by reducing administrative costs, funding for scheme </li></ul><ul><li>Policy makers must therefore carefully design such a subsidy policy cognizant of its financial implications, feasibility and sustainability of the policy. </li></ul>[Uganda]

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